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COMPLICATIONS

Pediatric
● Honey (especially raw or wild) is not recommended for children under age 1 due to the risk for infant botulism.
○ An infant under age 1 has an immature gut system that can allow Clostridium botulinum spores contaminated in honey to
colonize the gastrointestinal tract and release toxin that causes botulism.
○ Botulinum toxin produces muscle paralysis by inhibiting the release of acetylcholine at the neuromuscular junction.
Infants often present with constipation, diminished deep tendon reflexes, and generalized weakness.
○ Additional symptoms are lack of head control, difficulty in feeding, and decreased gag reflex, which can progress to
respiratory failure.
○ Isolation of the organism from the child's stool can take several days; therefore, diagnosis is usually made by history, and
treatment with botulism immune globulin is started before laboratory results are known.
● When a child is experiencing acute diarrhea, the priority is to monitor for dehydration. Treatment is accomplished with oral
rehydration solutions and early reintroduction of the child's normal diet (usual foods).
● Dental caries
○ Form when bacteria (eg, Streptococcus mutans) digest carbohydrates in the mouth, producing acids that break down
tooth enamel and cause mineral loss.
○ Oral hygiene, feeding practices, and dietary intake are significant factors contributing to the development of caries.
○ Increased risk of caries development is associated with a high intake of cariogenic foods, including refined, simple sugars
in any form; sweet, sticky foods such as dried fruit and candy; and sugary beverages such as colas and other carbonated
beverages, fruit drinks, and juices.
○ Some foods are cariostatic and can have an inhibitory effect on the progression of dental caries. Examples include dairy
products, whole grains, fruits and vegetables, and sugar-free gum containing xylitol. Additional practices that assist in
preventing caries include the following:
■ Brushing after meals
■ Flossing at least twice a day
■ Rinsing the mouth with water after meals or snacks (Option 4)
■ Drinking tap water rather than bottled water (Most tap water sources have fluoride added to the water supply
to promote dental health whereas most bottled water does not contain fluoride.)
■ Finishing meals with a high-protein food
● Fecal Incontinence (ie, encopresis, soiling)
○ Repeated passage of stool in inappropriate places by children age ≥4 years. In more than 80% of cases, it is due to
functional constipation (retentive type); in about 20% of cases, it may be caused by psychosocial triggers (nonretentive
type).
○ Management of fecal incontinence/constipation primarily includes 3 components:
■ Disimpaction followed by prolonged laxative therapy, dietary changes (increased fiber and fluid intake), and
behavior modification.
■ Behavioral strategies are used to promote and restore regular toileting habits and to gain the child's
cooperation and participation in the treatment program. Behavioral interventions include the following:
● Regularly scheduled toilet sitting times 5-10 minutes after meals for 10-15 minutes (Option 4)
● Provide a quiet activity for the child during toilet sitting, which will help pass the time and make the
experience more "enjoyable"
● Initiate a reward system to boost the child's participation in the treatment program; the reward
would be given for effort, not for success of evacuation in the toilet (children with retentive
encopresis have dysfunctional anal sphincters and little control over bowel movements; giving a
reward for something the child has no control over would not be effective)
● Keep a diary or log of toilet sitting times, stooling, medications, and episodes of soiling to evaluate
the success of the treatment
● Physiologic Anorexia
○ Occurs when the very high metabolic demands of infancy slow down to keep pace with the moderate growth of
toddlerhood.
 ○ During this phase, toddlers are increasingly picky about their food choices and schedules. Although to the parents it may
appear that the child is not consuming enough calories, intake over several days actually meets nutritional and energy
needs.
○ Parents should be educated concerning what constitutes a healthy diet for toddlers and which foods they are more likely
to consume.
○ Some strategies for dealing with a toddler during a stage of physiologic anorexia and pickiness include:
■ Set and enforce a schedule for all meals and snacks
■ Offer the child 2 or 3 choices of food items
■ Do not force the child to eat
■ Keep food portions small
■ Expose the child repeatedly to new foods on several separate occasions
■ Avoid TV and games during meals or snacks

● Pyloric stenosis
○ Presents with postprandial projectile vomiting (ejected up to 3 feet) followed by hunger (eg, "hungry vomiter").
■ This is clearly distinguished from the "wet burps" infants have due to a weak lower esophageal sphincter.
■ The emesis is nonbilious as the obstruction is proximal to the bile duct.
○ A palpable olive-shaped mass in the epigastrium to the right of the umbilicus is noted
○ Infants have poor weight gain and are often dehydrated (eg, sunken fontanelle, decreased skin turgor, delayed capillary
refill).
○ The amount of milk consumed (particularly with bottle feedings) along with the mother's technique (mainly adequate
burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology.
● Intussusception
○ One segment of the bowel telescopes into another.
○ The classic clinical triad is intermittent, severe, crampy abdominal pain; a palpable"sausage-shaped" mass on the right
side of the abdomen; and "currant jelly" stools. Other manifestations include inconsolable crying, drawing the knees up
to the chest during episodes of pain, and vomiting.
■ The child may appear normal and comfortable between episodes.
○ Reduction of intussusception is often performed with a saline or air enema.
○ The HCP should be notified if there is passage of a normal stool as this indicates reduction of the intussusception.
■ All plans for surgery should be stopped and the plan of care should be modified.
● Esophageal atresia (EA) and tracheoesophageal fistula (TEF)
○ Occur when the esophagus and trachea do not properly separate or develop.
○ In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus connects to
the primary bronchus or the trachea through a small fistula.
○ EA/TEF can usually be corrected with surgery.
○ Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, and drooling. Clients may also develop apnea
and cyanosis during feeding. Aspiration is the greatest risk for clients with EA/TEF, and newborns who demonstrate signs
of the condition are immediately placed on nothing by mouth (NPO) status.
○ A newborn with EA/TEF may have a distended abdomen due to the buildup of air in the stomach via the fistula from the
trachea to the lower esophagus.
○ Priority nursing interventions for infants with suspected EA/TEF include maintaining NPO status, positioning the client
supine, elevating the head at least 30 degrees, and keeping suction equipment by the bed to clear secretions from the
mouth. If surgery must be staged or delayed due to the infant's condition, the priority is to maintain a clear airway and
prevent aspiration.
● Gastroesophageal Reflux (GER)
○ Attributed to an immature lower esophageal sphincter.
○ If an infant is gaining weight and meeting developmental milestones, treatment is aimed at controlling the symptoms.
○ Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in cardiopulmonary
resuscitation. For at least 30 minutes after feeding, these infants should not be rocked or agitated by active play but
should be kept calm and upright.
○ Infants with GER should be offered small frequent feedings and not be pushed to complete a feeding when
demonstrating satiety.
○ To minimize reflux, the feedings should be interrupted after every 1-2 ounces for burping the infant as waiting until the
feeding is complete will increase the chance of regurgitation.
○ Maintaining the infant in an upright position during and after feedings will minimize spitting up. Infants should not be
placed in a car seat after feedings as this can increase intra-abdominal pressure, causing reflux. An infant's head should
be elevated 30 degrees when placed in an infant seat.
● Hirschsprung's Disease
○ A portion of the colon has no innervation and must be removed.
○ Some children require a temporary colostomy.
■ The stoma created from the surgery should remain beefy red in the immediate postoperative period. Any
paleness or graying of the stoma indicates decreased blood supply to that area.
Celiac Disease
● The body is unable to process gluten, a protein found in most grains. Gluten consumption will damage the villi of the small intestine;
this results in malabsorption of fats (steatorrhea, foul-smelling stools) and other nutrients, which can lead to malnutrition and failure
to thrive.
● The following are important principles to teach clients with celiac disease:
○ All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, oats or wheat
(BROW).
○ Rice, corn, and potatoes are gluten free and are allowed on the diet.
○ Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced.
○ Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch,
malt, and soy sauce. Food labels should indicate that the product is gluten free.
○ Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of
nutritional deficiencies and intestinal cancer (lymphoma).
○ Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms.
All sources of gluten must be eliminated from the diet.
Liver
● Laboratory abnormalities common in liver failure include:
○ Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules.
The liver has a decreased ability to conjugate and excrete bilirubin.
○ Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood
clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated
partial thromboplastin time [aPTT]) are usually elevated.
○ Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by
the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia
crosses the blood-brain barrier and results in hepatic encephalopathy.
○ Albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so
hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of vascular spaces into interstitial
spaces (eg, edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb (conserve) both sodium and
water. The large amount of water in the body results in a dilutional effect (low sodium).
● Discomfort is often due to pressure of the ascites fluid on the surrounding organs. Shortness of breath occurs due to the upward
pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion.
○ Positioning the client in a Semi-Fowler's or Fowler's position can promote comfort, as this position can reduce the
pressure on the diaphragm
○ Side-lying with the head elevated can also be a position of comfort for the client with ascites, as it allows the client's
heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation.
● Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruritus. It is
important to use a specialty mattress and implement a turning schedule for every 2 hours.
● A distraction can take the client's mind off the current symptoms and may also help to promote comfort in many different situations.
Some of these distractions include listening to music, watching television, playing video games, or taking part in other hobbies.
● May experience pruritus (itching) due to buildup of bile salts beneath the skin.
○ The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to
the skin from scratching.
○ Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated
skin.
○ Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in the feces, thereby decreasing
pruritus. It is packaged in a powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be
given one hour after all other medications are administered.
● Clients with cirrhosis should a eat high-calorie, high-carbohydrate, low-sodium, and low-fat diet; moderate protein intake is
recommended. They should avoid hepatotoxic substances (eg, alcohol, acetaminophen) and medications (NSAIDs) that increase
bleeding risk and reduce activities that increase intraabdominal pressure.
● Hepatitis
○ B is primarily through the unprotected sexual intercourse and intravenous illicit drug use. Blood, semen, saliva, and
vaginal secretions (body fluids) transmit hepatitis B infection.
○ C is transmitted predominantly through intravenous illicit drug use. Blood transfusion is now a rare mode of transmission
(unlike prior to 1990) for hepatitis C given the routine testing that began after 1990.
○ A occurs through the fecal-oral route via poor hand hygiene and improper food handling by those infected by hepatitis A.
○ Nursing interventions for the acute phase of hepatitis focus on resting the liver and providing nutrition for healing:
■ Rest

● Alternate periods of rest and activity (Option 3)

● Avoid alcohol and other drugs that increase liver metabolism (Option 5)
 ● Medications (eg, appetite stimulants, antipruritics, analgesics) should be used cautiously to allow
hepatocytes to heal. Antiemetics can be used to prevent nausea (Option 1).
■ Nutrition

● Encourage small, frequent meals to decrease nausea. Anorexia is lowest in the morning; promote
eating a larger breakfast (Option 2).
● Provide oral care and avoid extremes in food temperature to increase appetite
● Drink adequate amounts of fluid (2500-3000 mL/day) and encourage a diet high in carbohydrates
and calories
● Hepatic Encephalopathy (HE)
○ Serious complication of end-stage liver disease (ESLD) that results from inadequate detoxification of ammonia from the
blood.
○ Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from
accumulation of ammonia and other toxic substances in blood.
○ Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and
clients are not oriented to time, place, or person. A characteristic clinical finding of HE is presence of asterixis (flapping
tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists. Another sign is fetor
hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts.
○ Lab abnormalities common in liver failure include low albumin, elevated INR, and elevated liver function tests.
■ A low serum potassium can increase the risk of hepatic encephalopathy and should be reported to the health
care provider.
■ Elevated serum ammonia confirms the hepatic encephalopathy diagnosis.
○ If encephalopathy continues to worsen, medical treatment should include higher doses of lactulose and rifaximin, and
discharge should be delayed until the client is stable.
■ Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an
acidic environment and a hyperosmotic effect (laxative). In this acidic environment, ammonia (NH3) is
converted to ammonium (NH4+) and excreted rapidly. Lactulose can be given orally with water, juice, or milk
(to improve flavor) or it can be administered via enema. For faster results, it can be administered on an empty
stomach.
■ The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore,
the dose is titrated until the therapeutic effect is achieved.
■ The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can
cause dehydration, hypernatremia, and hypokalemia.

Pancreatitis
● Acute inflammation of the pancreas that results in autodigestion.
● The client with acute pancreatitis will report a sudden onset of unrelenting, severe pain in the left upper quadrant or midepigastric
area of the abdomen that often radiates to the back.
○ Pain improves with leaning forward and worsens with lying flat. The pain is often preceded or made worse by a high-fat
meal. Nausea and vomiting are common due to severe pain.
● The most common causes are cholelithiasis and alcoholism.
● Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the pancreas. The
pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include hyperglycemia, hypovolemia
(capillary leak → third spacing), latent hypoxia or acute respiratory distress syndrome (ARDS), peritonitis, and hypocalcemia.
○ Chvostek's (facial twitching) and Trousseau's (carpal spasm) signs are an indication of hypocalcemia from the decrease in
threshold for contraction. Sustained muscle contraction (tetany) and decreased cardiac contractility (cardiac arrhythmia)
are concerns related to hypocalcemia.
● A high-grade fever or abrupt increase in temperature with worsening abdominal pain could be an indication of a pancreatic abscess,
a significant complication of acute pancreatitis.
○ A pancreatic abscess requires immediate intervention (eg, antibiotics, surgical drainage) to reduce the risk of rupture and
sepsis; therefore, the health care provider should be notified immediately.
● Clients are at risk of developing hypovolemia (third spacing of fluids), acute respiratory distress syndrome (due to intense systemic
inflammatory response), and hypocalcemia (necrosed fat binding calcium).

Diverticulitis
● Diverticula are sac like protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal
pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop.
● The etiology of diverticular disease has been linked to chronic constipation, a major cause of excess intracolonic pressure.
Preventing constipation may help reduce the risk of diverticula forming and becoming inflamed.
○ Measures to prevent constipation include a diet high in fiber (whole grains, fruits, vegetables), daily intake of at least 8
glasses of water or other fluids, and exercise. A fiber supplement such as psyllium or bran may be advised. In the past,
clients have been taught to avoid consuming seeds, nuts, and popcorn; however, current evidence does not indicate that
avoidance of these foods will prevent an episode of diverticulitis.
 ● Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool.
● When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left lower quadrant)
and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis).
● Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and
intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound
tenderness).
○ The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum.
Peritonitis is a potentially lethal complication and should be reported immediately.
● Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes the following:
○ IV antibiotic therapy – to cover the gram-negative and anaerobic organisms that reside in the colon and contribute to
diverticulitis; these commonly include metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or
Bactrim DS; Septra) or ciprofloxacin (Cipro)
○ NPO status – more acute cases require complete rest of the bowel (NPO status); less severe cases may be handled at
home, and clients may tolerate a low-fiber or clear liquid diet
○ NG suction – in severe cases of abdominal distention, nausea, or vomiting
○ IV fluids – prevent dehydration
○ Bed rest
○ Preventing increased intestinal motility – avoid laxatives and enemas
○ Any procedure or treatment that increases intra abdominal pressure or may cause rupture of the inflamed diverticula
should be avoided.

Iron-deficiency Anemia
● Occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin. Iron-deficiency anemia can result
from:
○ Diets low in iron (eg, vegetarian and low-protein diets)
○ Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome)
○ Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding)
○ Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids])
● Foods rich in iron include:
○ Meats (eg, beef, lamb, liver, chicken, pork)
○ Shellfish (eg, oysters, clams, shrimp)
○ Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal
● Key instructions for safe, effective administration of oral iron supplements include:
● Administer between meals - Concentrations of stomach acid are higher between meals, breaking down the iron to an
easily absorbed state
● Give with citrus juice - Absorption is enhanced when taken with a good source of vitamin C, such as orange juice or other
citrus fruit
● Place medicine at the back of the mouth - Liquid iron can cause temporary staining of the teeth. Using a dropper or straw
to direct the iron toward the back of the mouth can reduce this risk.
● Avoid giving with milk - Milk and other products with high amounts of calcium reduce adequate absorption of iron
supplements
● Keep no more than a 1-month supply on hand - When ingested in extreme quantities, iron can be toxic or even lethal.
Only short-term amounts should be stored in the home, in a childproof location.

Lactase Deficiency (lactose intolerance)

● Experience varying degrees of gastrointestinal symptoms after ingesting milk products, including flatulence, diarrhea, bloating, and
cramping. This is due to a deficiency of the enzyme lactase, which is required for digestion of lactose.
● Treatment includes restricting lactose-containing foods in the diet. These clients may also take lactase enzyme replacements (eg,
Lactaid) to decrease symptoms. Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified
milk.

Dumping Syndrome
● Occurs when gastric contents are emptied too rapidly into the duodenum and cause a fluid shift into the small intestine.
● This fluid shift results in hypotension, abdominal pain, diarrhea, nausea, vomiting, dizziness, generalized sweating, and tachycardia.
The symptoms usually diminish over time.
○ Dietary recommendations are aimed at delaying gastric emptying and include the following:
 ■ Small, frequent meals reduce the amount of food in the stomach at any one time. Eat slowly in a relaxed
environment.
■ Avoid meals high in simple carbohydrates, as these may trigger dumping syndrome as the carbohydrates are
broken down into simple sugars. Instead, consume meals high in protein, fat, and fiber, as these take longer
to digest and will remain in the stomach longer than carbohydrates.
■ Separate fluids from meals. If fluids are taken with meals, stomach contents pass more easily into the jejunum
and worsen symptoms. Fluid intake should be only after or between meals, separated from solid intake by at
least 30 minutes.
■ Avoid sitting up after a meal. Gravity increases gastric emptying. Lying down after meals slows down the
gastric emptying and is preferred.

Bowel Obstruction
● Small-bowel Obstruction
○ Mechanical obstruction is commonly caused by obstruction of the bowel resulting from surgical adhesions, hernias,
intussusception, or tumors.
○ Paralytic ileus, a non-mechanical obstruction, may occur after abdominal surgery or narcotic use.
○ Fluid and gas collect proximal to the obstruction, producing rapid onset of nausea and vomiting, colicky intermittent
abdominal pain, and abdominal distension.
■ The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular
compromise, bowel ischemia, or perforation.
■ Nursing management of an obstruction includes placing the client on NPO status, inserting a nasogastric tube,
administering prescribed IV fluids, and instituting pain control measures.
● Large-bowel obstruction differ slightly from small-bowel obstruction and include gradual onset of symptoms, cramping abdominal
pain, abdominal distension, absolute constipation, and lack of flatus.
○ Constipation and decreased flatus resulting from small-bowel obstruction would occur later, as the stool and gas in the
large colon would be expelled for a few days.

Cholecystitis
● Pain in the RUQ with referred pain to the right shoulder and scapula.
● Clients often report fatty food ingestion 1–3 hours before the initial onset of pain.
● Associated symptoms include low-grade fever, chills, nausea, vomiting, and anorexia.
● During an acute attack, inflammation of the mucous lining and wall of the gallbladder occurs as a result of gallstone(s) obstruction of
the cystic bile duct.
○ The inflammation and increased pressure in the gallbladder from the blocked bile duct results in Murphy's sign; palpation
over the RUQ causes pain and inability to take a deep breath.
● The highest priority intervention for an actively vomiting client with cholelithiasis is maintenance of strict NPO status to avoid
additional gallbladder stimulation. Additional priorities include management of nausea and vomiting, pain, fluid balance, and gastric
decompression.

Hiatal Hernia
● Conditions that increase intra abdominal pressure (eg, pregnancy, obesity, ascites, tumors, heavy lifting) and weaken the muscles of
the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm, causing a hiatal hernia.
○ A sliding hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm.
○ A paraesophageal hernia (rolling hernia) occurs when the gastroesophageal junction remains in place but a portion of
upper stomach folds up along the esophagus and forms a pocket. Paraesophageal hernias are a medical emergency.
● Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated with
gastroesophageal reflux disease (GERD), including heartburn, dysphagia, and pain caused by increased intra abdominal pressure or
supine positioning. Interventions to reduce herniation include the following:
○ Diet modification—avoid high-fat foods and those that decrease lower esophageal sphincter pressure (eg, chocolate,
peppermint, tomatoes, caffeine). Eat small, frequent meals, and decrease fluid intake during meals to prevent gastric
distension. Avoid consumption of meals close to bedtime and nocturnal eating.
○ Lifestyle changes—smoking cessation, weight loss.
○ Avoid lifting or straining.
○ Elevate the head of the bed to approximately 30 degrees—this can be done at home using pillows or 4 - 6 inch blocks
under the bed.

Refeeding Syndrome
● Lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral
feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of
electrolytes from the blood into tissue cells for anabolism.
 ● The key signs of refeeding syndrome are rapid declines in phosphorus, potassium, and/or magnesium. Other findings may include
fluid overload, sodium retention, hyperglycemia, and thiamine deficiency.
● Actions to prevent refeeding syndrome include the following:
○ Obtaining baseline electrolytes
○ Initiating nutrition support cautiously with hypocaloric feedings
○ Closely monitoring electrolytes
○ Increasing caloric intake gradually

Appendicitis
● The appendix is a blind pouch located at the junction of the ileum of the small intestine and the beginning of the large intestine
(cecum). When infected or obstructed (foreign body, fecal material, tumor, lymph tissue), the appendix becomes inflamed, causing
acute appendicitis. Signs and symptoms of acute appendicitis include the following:
○ Pain: Continuous; begins in the periumbilical region and then moves to the right lower quadrant centering at McBurney's
point (one-third of the distance from the right anterior superior iliac spine to the umbilicus)(Option 3)
○ Gastrointestinal symptoms: Anorexia, nausea, and vomiting
○ Rebound tenderness and guarding
● Clients with acute appendicitis attempt to decrease pain by preventing increased intraabdominal pressure (eg, avoiding coughing,
sneezing, deep inhalation) and lying still with the right leg flexed.
● The appendix may rupture if left untreated, placing the client at risk for peritonitis, a potentially fatal infection of the peritoneum.
● When prioritizing multiple prescriptions, the nurse should first address issues of airway, breathing, circulation, and then vital signs.
Initial interventions for acute appendicitis may include the following:
○ Ensure patent airway and administer oxygen if hypoxic
○ Obtain IV access and administer prescribed fluids
○ Draw blood samples for complete blood count (CBC), electrolyte levels, clotting studies, and type and cross as prescribed
○ Insert indwelling urinary catheter and obtain urine sample for urinalysis, if prescribed
○ Insert a nasogastric (NG) tube if necessary

Peptic ulcer disease (PUD)

● Client teaching includes lifestyle changes (eg, dietary modifications, stress reduction), PUD complications, and medication
administration.
● Helicobacter pylori infection and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are risk factors for complicated PUD.
● H pylori treatment includes antibiotics and proton-pump inhibitors for acid suppression. The recommended initial treatment is 7-14
days of triple-drug therapy with omeprazole (Prilosec), amoxicillin, and clarithromycin (Biaxin).
● Ulcerative Colitis
○ Inflammation and ulcerations in the large intestines resulting in urgent, frequent, bloody diarrhea; abdominal pain;
anorexia; and anemia.
○ A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet
the nutritional and metabolic needs of the client with ulcerative colitis.
■ The low-residue diet limits trauma to the inflamed colon and may lessen symptoms.
■ Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender
meats are included in the diet.
■ Raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol are avoided. d

Hemorrhoids
● Distended, inflamed veins located in the anus or lower rectum.
● Caused by increased anorectal pressure (straining to defecate, constipation). Clients may experience symptoms such as rectal
bleeding, pain, pruritus, and prolapse. Although removal of hemorrhoids (hemorrhoidectomy) is a minor procedure, the pain
associated with it is due to spasms of the anal sphincter and is severe.
● Nursing management for the post-hemorrhoidectomy client includes the following:
○ Pain relief: Initially, pain is managed with pain medications, including nonsteroidal anti-inflammatory drugs (eg,
ibuprofen) and/or acetaminophen; opioids can be prescribed initially but may worsen constipation. Beginning 1-2 days
postoperatively, warm sitz baths are used as a means to relieve pain. Clients often dread their first bowel movement due
to severe pain with defecation. Therefore, pain must be appropriately controlled to prevent further constipation.
○ Preventing constipation: Encourage a high-fiber diet and adequate fluid intake (at least 1500 mL/day). Administer a stool
softener such as docusate (Colace) as prescribed. An oil-retention enema may be used if constipation persists for 2-3
days .
○ Postoperatively, the health care provider may pack the rectum and apply a T-binder to hold the packing in place. The
dressing is usually removed 1-2 days postoperatively unless excess soaking is noted before.
 ○ Warm sitz baths are used beginning 1-2 days postoperatively, 2-3 times daily (15-20 minutes each) for 7-10 days to
provide pain relief, decrease swelling, and cleanse the rectal area.

Constipation
● Symptom of many different disease processes (eg, Parkinson's disease, diabetic neuropathy, depression), procedures (eg, abdominal
surgery, bowel manipulation), and medications (eg, anticholinergics, diuretics, opioids, antacids, antihypertensives). Immobility,
low-fiber diets, decreased fluid intake, and irregular bowel habits increase the likelihood of constipation. Teach the client and/or
caregiver the following to prevent constipation:
○ Consume 20-30 g of fiber a day (unless contraindicated); fiber softens stool and increases bulk, stimulating defecation.
High-fiber foods include fruits, vegetables, whole grains, nuts, seeds, and legumes
○ Drink 2-3 L of fluids a day (unless contraindicated); avoid caffeinated beverages (eg, coffee, tea, cola) that promote
diuresis.
○ Exercise at least 3 times a week; movement stimulates peristalsis and defecation
○ Maintain a healthy bowel regimen – avoid delaying defecation when the urge is felt, defecate at the same time each day,
and track bowel movements to identify if there is a change in bowel patterns
○ Avoid laxatives and enemas unless prescribed by a healthcare provider; overuse can cause dependency

Lead Poisoning
● Two common sources of exposure are lead-based paints and contaminated soil found in or around houses built before 1978, when
these paints were banned. Other sources include water from old pipes, glazed pottery, and imported toys.
● Blood lead level (BLL) screenings are recommended at ages 1 and 2, and up to age 6 if the child has not been screened previously.
● Children with elevated BLLs (≥5 mcg/dL) require close monitoring and follow-up blood work to ensure that levels decrease.
○ If BLLs are not reduced with home interventions, chelation therapy may be needed.
○ Affects the neurological system, elevated BLLs are dangerous in young children due to immature development of the
brain and nervous system.
○ A mild to moderate increase in BLL can manifest with hyperactivity and impulsiveness; prolonged low-level exposure can
cause developmental delays, reading difficulties, and visual-motor issues.
○ Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, blindness, or even death.
● The priority intervention is to prevent continued lead exposure.
○ Parents should have their home evaluated for lead sources (eg, old paint, lead pipes) (Option 1).
■ If renovations are required, children and pregnant women should not live in the home until this work is
complete.
○ Frequent handwashing is important to remove lead residue, particularly before eating (Option 3). Proper intake of iron
and vitamin C decreases lead absorption.
○ Vacuuming in an older home can spread lead-containing dust into the air that can be inhaled. Hard-surfaces should be
wet dusted or mopped at least weekly.
○ Hot water can dissolve lead from older pipes; therefore, only cold water should be used for cooking if contaminated pipes
are a concern. Taps should be flushed for several minutes to clear out contaminated water before use.
INTERVENTIONS

Ostomy

● A client who has undergone ostomy surgery must become independent in self-care. This requires adaptation to a significant
alteration in body image and dealing with a number of psychosocial issues that are associated with a change in appearance and the
loss of bowel control. It is not uncommon for a client to cope with this loss by refusing to look at or participate in the care of the
stoma. Nursing interventions for this client will include:
○ Supportive counseling and assistance in psychosocial adjustment
○ Teaching and facilitating self-care
○ Providing information about the reason for the surgery, prognosis, potential complications, and community resources
○ The priority outcome of nursing care is that the client will look at and touch the stoma; this is an indication that the client
has accepted or begun to accept the change in body image and functioning and can begin participating in self-care.
● Colostomy
○ Surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass an
obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the
skin.
○ Proper care of the stoma and pouch appliance that should be taught to the client or caregiver includes the following:
■ Ensure sufficient fluid intake (at least 3,000 mL/day unless contraindicated) to prevent dehydration; identify
times to increase fluid requirements (hot weather, increased perspiration, diarrhea)
■ Identify and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, brussels sprouts)
■ Empty the pouch when it becomes one-third full to prevent leaks due to increasing pouch weight.
○ Clients with a descending or sigmoid colostomy drain stool that is more formed and similar to a normal bowel movement.
Although less common, some clients choose to irrigate their colostomy in order to create a bowel regimen that allows
 them to wear a smaller pouch or a dressing over the stoma. When irrigated daily, the client gains increased control over
the passage of stool. The procedure for bowel irrigation is as follows:
■ Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang
the container on a hook or intravenous pole
■ Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the
toilet, and place the irrigation container approximately 18-24 inches above the stoma
■ Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place
■ Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes
■ Clamp the tubing if cramping occurs, until it subsides
■ Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the
sleeve into the toilet
● Ileostomy
○ In the immediate postoperative period, a low-fiber diet is prescribed to prevent obstruction of the narrow lumen of the
small intestine and stoma (1 inch [2.54 cm] diameter or less). Foods to be avoided include the following:
■ Stringy texture: celery, broccoli, asparagus stalks
■ High fiber: bread, brown rice, oatmeal
■ Seeds or pits: strawberries, raspberries, olives
■ Edible peels: apple slices, raw cucumber, dried fruits
■ Nuts: peanuts, almonds, cashews
● Fruits and vegetables can be enjoyed if pitted, peeled, and/or cooked
● Low-fiber carbohydrate options include white rice, refined grains or pastas, or cooked cereals
● The client should also be taught to thoroughly chew food before swallowing. As the remaining intestines adapt, the
client's diet can be advanced as tolerated with the goal of returning to the client's preoperative diet.

Ileal Conduit
● Surgical technique that uses an excised piece of the client's ileum to create an incontinent urinary diversion. The client's ureters are
connected to the ileal conduit, which is used to create an abdominal stoma that allows the passage of urine.
○ A healthy stoma should be pink to brick-red and moist, indicating vascularity and viability. If the stoma is dusky or any
shade of blue, the nurse should suspect impaired perfusion and contact the HCP immediately. This finding is considered a
medical emergency.
○ Infection is a potential complication; signs and symptoms of infection may include fever, elevated white blood cell count,
odor, and delayed healing.
○ Applying an appropriate-size pouching system (approximately 0.1 in [0.25 cm] larger than the stoma) prevents decreased
perfusion and skin irritation. Using a larger drainage bag, especially at night, prevents urine backflow through the stoma
and reduces the risk for infection.

ALT and AST

● Enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues,
but ALT/AST are used to diagnose hepatic disorders.
● Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake, some over-the-counter medications (eg,
acetaminophen), and certain herbal and dietary supplements. IV illicit drug use increases the risk for hepatitis B and C infection.

Pediatric
 ● Before age 6 months, an infant should receive only breast milk or formula.
● The infant is ready physiologically and developmentally for the addition of solid foods to the diet at age 4-6 months as iron stores
have declined.
○ Iron-fortified cereals (rice, barley, oatmeal, high protein) should be offered.
○ Rice cereal is preferred due to the low risk of allergy and ease of digestion. Cereal can be mixed with breast milk,
formula, or water.
● When introducing new foods, it is important to allow 5-7 days between foods to observe for any allergies to a particular food.
● Foods are introduced one at a time to identify any allergies. Foods known to commonly induce allergy (eg, peanuts, eggs, seafood,
whole milk) should not be introduced before age 1 year.
● When choosing snacks and meals for toddlers (age 1–3), 3 factors must be considered:
○ Safety – small, hard, sticky and/or slippery foods pose a choking risk and should not be offered to children under age 3.
Examples include hot dogs, grapes, nuts, raw carrot sticks, popcorn, peanut butter, hard candy, and raisins.
○ Nutrient density (the nutrients a food provides relative to the number of calories it contains). The snack should be of
high nutritional value rather than "empty calories."
○ Potential for food-borne illness – children are at higher risk for developing a food-related infection if given raw,
unpasteurized foods such as juice, partially cooked eggs, raw fish, or raw bean sprouts.

● The recommendation from pediatric professional organizations, including the American Dental Association and the American
Academy of Pediatrics, is that children have their first visit to the dentist at or near age 1. The purpose of the first visit includes the
following:
○ Assess risk for dental disease
○ Provide dental care and treatment of dental caries
○ Provide anticipatory guidance about dental hygiene, fluoride, diet and dietary habits, and non-nutritive sucking
○ Establish a dental home and schedule future visits

● Taking a child to the dentist at an early age also helps to accustom the child to the dentist's office, oral examinations, and care.
Judaism
● Follow Kosher laws. These regulations are strict regarding the use of certain animal products (eg, no pork, shellfish, fish without
scales) and the separation of meat/poultry from dairy.
● When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product can be consumed.
● Certain foods, including fresh fruits and vegetables, grains, tea, and coffee, are considered neutral and can be consumed at any time.
● Pita chips and hummus are non-dairy foods and would be an appropriate snack.
Scopy (Any procedure in which a firm scope is inserted into a "hollow tube" organ)
● Risk include perforation and rectal bleeding: abdominal pain (with shoulder tip pain), positive rebound tenderness, guarding,
abdominal distension, tenesmus, increased temperature and/or boardlike (rigid) abdomen. .
● Colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no stool left for
better visualization during the procedure. These instructions include:
○ Clear liquid diet the day before
○ Nothing by mouth 8–12 hours prior to the examination
 ○ The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene glycol
(GoLYTELY) the day before the test. The type of prep depends on the health care provider's preference and client health
status.
Total parenteral nutrition (TPN)
● A complication of TPN is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue,
and blurred vision. The development of hyperglycemia is related to the following:
○ Excessive dextrose infusion
○ A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of
counterregulatory hormones
○ High infusion rate
○ Administration of medications such as steroids
○ Infection
■ Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the
TPN solution, slowing down the infusion rate, and administering subcutaneous insulin.

Paracentesis
● Performed to remove excess fluid from the abdominal cavity or to provide a specimen of ascitic fluid for diagnostic testing.
Paracentesis is not a permanent solution for resolving ascites and is performed only if the client is experiencing impaired breathing
or pain due to ascites. Nursing actions include:
○ Explain the procedure, sensations, and expected results
○ Instruct the client to void to prevent puncturing the bladder
○ Assess the client's abdominal girth, weight, and vital signs
○ Place the client in high Fowler's position and remain with the client during the procedure
○ After the procedure, assess and bandage the puncture site and reassess client weight, girth, and vital signs

Drainage Devices
● The general procedure for emptying the drainage device includes the following steps in order:
○ Perform hand hygiene as asepsis must be maintained to prevent the transmission of microorganisms even though there
is less chance of bacteria entering the wound using a closed-wound drainage device (eg, JP, Hemovac) than an open-drain
device (eg, Penrose)
○ Pull the plug on the bulb to open the device and pour the drainage into a small, calibrated container(eg, plastic water
cup, urine specimen container) as this facilitates recording accurate drainage output
○ Empty the device every 4-12 hours unless it is 1/2 to 2/3 full before then because as the small capacity bulb (100 mL) fills,
the amount of negative pressure in the bulb decreases
○ Compress the empty bulb by squeezing it from side-to-side with 1 or 2 hands until it is totally collapsed. Although the
reservoir can be collapsed by pressing the bottom towards the top, compressing the sides of the reservoir (bulb) is
recommended as it is more effective in establishing negative pressure
○ Clean the spout on the bulb with alcohol and replace the plug when it is totally collapsed to restore negative pressure

Obesity
● Sugary beverages, such as regular soft drinks, are key contributors to the excess consumption of calories and theobesity epidemic.
Individuals who are attempting to lose weight should consume beverages with few or no calories, including:
○ Water
○ Club soda (flavored or unflavored)
○ Club soda or sparkling water with a splash of fruit juice
○ Unsweetened tea and/or coffee
○ Non-fat or low-fat milk (in limited amounts)

Fecal Occult Blood Test (FOBT)

● FOBT is used to assess for microscopic blood in the stool and as a screening tool for colorectal cancer. The steps for collecting a
FOBT sample are as follows:
○ The nurse first communicates the purpose of the test to the client. An interview is conducted to assess recent ingestion
(within last 3 days) of red meat or vitamin C supplements as these may interfere with the test and produce false results.
A medication history is taken related to use of medications that might interfere with test results, including aspirin,
anticoagulants, iron, ibuprofen, and corticosteroids.
 ○ Obtain supplies, wash hands, and apply non-sterile gloves. Supplies include FOB slide, wooden applicator (tongue blade),
hemoccult developer, and clean gloves.
○ Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. Collect
the fecal samples from 2 different areas of the specimen as some portions of the stool may not contain microscopic
blood.
○ Close slide cover and allow the stool specimen to dry for 3-5 minutes.
○ Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide.
○ Assess the color of the hemoccult slide paper after 30-60 seconds. If the test paper turns blue, (a positive guaiac result),
the stool contains microscopic blood.
○ Place used gloves and wooden applicator in appropriate waste receptacle.
○ Perform hand hygiene.
○ Document the test results in the electronic medical record.

Continuous Suction
● Can be applied to decompress the stomach if a double lumen Salem sump tube is in place. The larger lumen is attached to suction
and the smaller lumen (within the larger one) is open to the atmosphere.
● The air vent (blue pigtail) must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its
distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa.
● If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level of the
client's stomach to prevent reflux.
● General interventions to maintain gastric suction using a Salem sump tube include:
○ Place the client in semi-Fowler's position to help keep the tube from lying against the stomach wall; this is done to help
prevent gastric reflux.
○ Provide mouth care every 4 hours as this helps to maintain moisture of oral mucosa and promote client comfort
○ Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds.
○ Inspect the drainage system for patency (eg, tubing kink or blockage).

Laparoscopic Cholecystectomy
● Postoperative nursing care after laparoscopic cholecystectomy focuses on prevention of respiratory complications.
○ The client is placed in the Sims' position to facilitate movement of carbon dioxide (CO2) utilized during surgery to fill the
abdominal cavity. CO2 can irritate the phrenic nerve and diaphragm, potentially causing breathing difficulty.
● Postoperative teaching includes:
○ Diet – a low-fat diet is recommended postoperatively as it is well tolerated. A regular diet can be resumed after a few
weeks although weight loss may be recommended.
○ Activity and work – resume normal activity slowly, as tolerated. Most individuals can return to work within a week.
○ Incision care and hygiene - dressings can be removed the day after surgery, and showering is permitted at this time. Signs
and symptoms of infection (redness, edema, pus, severe pain, nausea, fever, chills) should be reported immediately.

Small Bowel Follow Through

● An SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession.
● Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine.
● Using this technique, decreased motility (eg, ileus), increased motility (eg, malabsorption syndromes), fistulas, or obstructions are
identified.
● Clients should be instructed as follows:
○ Fast 8 hours prior to the examination.
○ The test usually takes 60-120 minutes, but if obstruction or decreased motility is present, it can take longer.
○ Drink plenty of fluids after the examination to facilitate barium removal. Chalky stools may be present 24-72 hours after
the examination. If brown stools do not return after 72 hours or abdominal pain or fullness is present, contact the HCP.

PEG Tube
● Inserted via a minor surgical procedure in which the tube passes through the stomach and abdominal wall.
● There are internal and external bumpers to hold the tube in place until the tract matures. The tract created starts to mature in 1-2
weeks, but it is not completely formed for 4-6 weeks.
● Dislodging before the tract matures can result in gastric contents spilling into the intraperitoneal cavity. When tube displacement
occurs within 1 week of the PEG procedure, placement must be done by surgery or repeat endoscopy.
○ If the displacement occurs after 1 week but before the tract matures, the placement must be confirmed by imaging or
aspiration of gastric content (acidic pH≤5).
 ● General PEG care includes pushing the tube forward toward the abdomen and rotating it daily to prevent adherence to the tract
while it matures.

MEDICATIONS

Pediatric
● Using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being
administered.
● The extrusion reflex and a decreased gag reflex in infants less than 4 months old increase the risk for choking and aspiration.
● Instilling the medication using a syringe at the back of the cheek decreases the risk for choking and ensures that the correct amount
of medication is consumed.

Proton Pump Inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole)

● Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption
of calcium and promote osteoporosis.
○ A bone density test can assess if the client already has osteoporosis.
● Hospitalized clients also have an increased risk of diarrhea caused by Clostridium difficile.
○ PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper
gastrointestinal tract. This leads to increased risk of pneumonias.

Metoclopramide (Reglan)
● Prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic.
● Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia
(TD). This is especially common in older adults with long-term use. The client should call the health care provider immediately if TD
symptoms develop, including uncontrollable movements such as:
○ Protruding and twisting of the tongue
○ Lip smacking
○ Puffing of cheeks
○ Chewing movements
○ Frowning or blinking of eyes
○ Twisting fingers
○ Twisted or rotated neck (torticollis)

Opioids
● Nausea and vomiting are expected side effects of opioid medications (eg, morphine sulfate) when the treatment is initiated.
● Tolerance develops quickly and persistent nausea is rare.
● It is recommended that the client take an antiemetic with the pain medication.
● Nausea and vomiting are decreased when the client lies still in a flat position.

Sulfasalazine (Azulfidine)
● Contains sulfapyridine and aspirin (5-ASA) and is used as a topical gastrointestinal anti-inflammatory and immunomodulatory agent
in irritable bowel disease.
● When the 5-ASA is combined with the sulfa preparation, the drug does not become absorbed until it reaches the colon. Dehydration
is a risk with IBD as the client can have up to 20 diarrheal stools a day.
● The client usually does not feel thirsty until after there is a fluid volume deficit. Sulfa can crystallize in the kidney if the client is
dehydrated.